Sample ESS Referral Form (EMBC2395) - Emergency Social Services

Ministry of Justice
REFERRAL
PLEASE PRESS HARD - YOU ARE MAKING 4 COPIES
NOTE TO SUPPLIER: Please attach itemized receipts and invoices providing specific details of goods and/or services along
with the original (white) copy of this Referral form and submit to Emergency Management BC. See reverse for more detailed
information and billing instructions.
If no Emergency Social Services (ESS) Rates sheet is attached to this Referral form, call 1-800-663-3456
3. NAME OF SUPPLIER
4. ADDRESS OF SUPPLIER
NOT REDEEMABLE FOR CASH
1. TASK # Referral #
2. ESS File # (if applicable)
123456
5. CITY 6. POSTAL CODE
7. TELEPHONE 8. FAX
( ) ( )
13.
At the request of the Community or District of
From
To
9.
HH / MM
(24 hour clock)
VALID ONLY
11. 12.
HH / MM
(24 hour clock)
14. NAME OF FAMILY REPRESENTATIVE (family name, first name)
10.
YYYY MM DD
YYYY MM DD
Please provide the following goods and services in accordance with the
Emergency Social Services Rates attached, to the following person(s):
16.
Number of Adults or Youths (13 - 18):
Names:
15. NAME OF PERSON PURCHASING GOODS (if different from family representative)
Number of Children (12 & under):
Names:
17.
NOTE TO ESS RESPONDER: Use one form for each different supplier AND Tick “YES” or “NO” for each category below
FOOD YES NO
20.
TRANSPORTATION
YES NO
Restaurant Meals OR Groceries
# persons:
Total # of meals per person during “Valid Only” period:
# of Breakfasts: # of Lunches: # of Dinners:
NOTE: Alcohol, tobacco and gratuities are not eligible expenses
Refer to attached ESS Rates sheet for maximum allowable rates
21.
Specify Mode of Travel:
From (address)
To (destination)
INCIDENTALS
YES NO
# of people: Specify approved items:
18.
LODGING
YES
NO
19.
Hotel/Motel OR Billeting OR Group Lodging
# of nights authorized: (maximum 3)
Refer to attached ESS Rates sheet for maximum allowable rates
CLOTHING
YES NO
NOTE: If more than one Referral form is issued for incidentals, the
total of all Referral forms must not exceed maximum allowable rate.
22.
Refer to attached ESS Rates sheet for maximum allowable rates
Comments:
# of people: Extreme winter conditions:
YES
NO
Refer to attached ESS Rates sheet for maximum allowable rates
The personal information requested on this form is collected under the authority of the Emergency Program Act and is necessary for administrative
purposes and may be shared with other public bodies, organizations and/or agencies only to enable the provision of emergency services. Disclosure of
personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Questions regarding the collection, use or
disclosure of this information should be directed to the Manager, Training , Exercise & Volunteer Programs, Emergency Management BC, PO Box 9201
Stn Prov Govt, Victoria, B.C. V8W 9J1 Phone: 1-800-585-9559
23. Signature of Family Representative 24. Interviewers first name and initial of last name (please print) 25. Date (YYYY MM DD)
NOTE TO SUPPLIER - Send original (white copy) of Referral form and itemized invoices to:
Emergency Management BC
Victoria BC
V8W 9J1
PO Box 9201, STN PROV GOVT
EMBC2395 7530906047 (100/pak) (13/06/01) White copy - Supplier Yellow Copy - Evacuee Pink Copy - ESS Office, EMBC (Victoria) Green Copy - Documentation Unit
PHONE
FAX
1-800-585-9559 (250) 952-4888

Information for Suppliers and ESS Responders
-- PLEASE READ --
IMPORTANT: An ESS Rates sheet must be attached. If no Rates sheet is provided, please confirm current rates prior
to providing services by contacting Emergency Management BC (EMBC), Emergency Coordination Centre (ECC) at
1-800-663-3456.
General Information
• Refer to the attached ESS Rates sheet for a description of eligible goods/services and maximum rates.
• Charges for goods and services, including all applicable taxes, must not exceed the attached Emergency Social Services
rates.
• Ensure that services are provided only to those individuals listed on the Referral form.
• Check “Valid Only” dates carefully. Services provided outside the time period will not be covered.
• Make note of any additional instructions that may be provided in the “Comments” section.
• An invoice is required with each Referral form, in addition to the corresponding itemized original receipts or till tapes.
• Alcohol, tobacco and gratuities are not covered.
• Groceries, clothing and incidentals are “one-time only” purchases.
• It is recommended that the supplier make copies of all documentation for their records.
Additional Lodging Information
• Other than the basic room charge and applicable taxes, all extra costs - including but not limited to, phone calls, movies,
parking, damage or theft - are the responsibility of the evacuee.
• If the evacuee can bill meals to their room, please ensure the restaurant has an ESS Rates sheet and is aware of the meal
allowances and restrictions. Itemized bills for meals provided must be included with the invoice.
• Billeting rate does not include meals. A Referral form for either groceries or restaurant meals may be issued.
Additional Restaurant Information
• Maximum meal allowances are set per meal, not per day. Meal allowances for the entire day cannot be combined into
one large food order, unless prior authorization is obtained from EMBC.
• An itemized bill for each meal must be included with your invoice.
For Use of Supplier
Invoice Checklist
The following checklist is provided for your convenience to ensure your invoice documentation is complete and accurate
prior to forwarding to Emergency Management BC (EMBC) for payment.
Original (white) copy of Referral form received from evacuee.
Invoice includes supplier’s name and address, and original itemized receipts/till tapes.
Write Referral # on upper right hand corner of all invoices and documents.
Goods or services rendered only to those people listed on the Referral.
Goods or services rendered are eligible items as listed on the ESS Rates sheet.
Goods or services rendered are within maximum rates as listed on the ESS Rates sheet.
Any exceptions have been authorized by EMBC and documented.
Make copies of invoices and receipts for your records.
Send original invoices and itemized receipts with white copy of Referral form to EMBC for payment.
EMBC2395(13/06/01)